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ADA Standards of Medical Care in Diabetes – 2022 Update

August 3, 2022

Every year, the American Diabetes Association (ADA) updates its evidence-based clinical practice guidelines, Standards of Medical Care in Diabetes. This article summarizes the changes most relevant to primary care practice.^[1,2,3] The full 2022 Standards of Medical Care is published annually in January as a supplement to Diabetes Care.^[4] Some of the most useful tools and tables have been developed into a free app for web browsers and iOS or Android phones.^[5] The Standards of Medical Care is treated by the ADA as a “living document” and was updated on May 31, 2022; the “update to the update” is included below in sections 10 and 11.^[6]

Improving Care and Promoting Health in Populations
Employ telemedicine to deliver patient-centered, team-based, chronic disease care addressing comorbidities and emphasizing education for self-management.
Classification and Diagnosis of Diabetes
Screening with laboratory-measured glycosylated hemoglobin (HbA1c) is recommended for obese/overweight children and adolescents with risk factors (e.g., family history of DM in first degree relative, racial/ethnicity groups, acanthosis nigricans) beginning at age 10. Because “maturity-onset diabetes in youth” (MODY) is epidemic in America, overweight young adults (18+) with risk factors (e.g., prediabetes, history of gestational diabetes, HIV, corticosteroid therapy, comorbidities like hyperlipidemia or hypertension) should be screened for diabetes and prediabetes. All adults should be screened beginning at age 35. Negative screenings should be repeated every 3 years or sooner if symptomatic or change in risk.
Prevention or Delay of Type 2 Diabetes and Associated Comorbidities
Lifestyle modification is still the preferred method of preventing progression of prediabetes to diabetes, but metformin therapy should be considered particularly if any of the following apply: age 25-59 years with BMI ≥ 35 kg/m²; higher fasting plasma glucose ≥ 110 mg/dL; higher A1C (≥ 6.0%); women with prior history of gestational diabetes.
Comprehensive Medical Evaluation and Assessment of Comorbidities
People with diabetes and prediabetes are at risk of adverse outcome from COVID-19 and full vaccination should be strongly encouraged. Patients with Type 2 diabetes or prediabetes and elevated liver enzymes or fatty liver on ultrasound should be evaluated for presence of nonalcoholic steatohepatitis and liver fibrosis.
Facilitating Behavior Change and Well-Being to Improve Health Outcomes
Digital coaching and digital self-management interventions can be effective methods to deliver diabetes self-management, education, and support (DSMES). Fiber content and food form (unprocessed vs. processed) is emphasized in addition to carbohydrate content. Patients with diabetes/prediabetes are at greater risk for cognitive impairment and screening should be considered if symptoms warrant.
Glycemic Targets
Assessment of glycemic status (A1C or other glycemic measurement such as time in range [TIR] or glucose management indicator [GMI]) measured over 14 days at leasttwice a year in patients who are meeting treatment goals (and who have stable glycemic control) and at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals.
Diabetes Technology
Continuous glucose monitoring (CGM) is highly recommended if both basal and intermittent insulin is being used and is preferred for patients on basal insulin only, but other technologies for blood glucose monitoring (BGM) are acceptable in those who cannot use CGM if the BGM is verified by other sources (e.g., medical office or laboratory confirmation). Insulin pens are preferred, but insulin syringes are acceptable in those who cannot afford pen and cartridge systems.

Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes
The 2022 Standards of Medical Care finds no evidence of benefit for dietary supplements for weight loss but all FDA approved drugs for treatment of obesity have evidence of benefit for glycemic control.

Pharmacologic Approaches to Glycemic Treatment
Insulin therapy for Type 1 diabetes should be individualized with an emphasis on avoidance of hypoglycemia. For Type 2 diabetes, lifestyle modification is crucial and pharmacotherapy should be selected to address any comorbidities, especially atherosclerotic cardiovascular disease (ASCVD), congestive heart failure and chronic kidney disease. In the absence of significant comorbidity, therapy should be optimized to minimize hypoglycemia, encourage weight loss in the overweight, and consideration of cost and access to treatment.

CVD and Risk Management
Lifestyle interventions and pharmacotherapies that control blood pressure, lipids, and hypoglycemic agents that interact favorably with agents for comorbidities are crucial to cardiovascular outcomes. Cardiovascular disease (CVD) is still the most common cause of mortality in people with diabetes. The approach to CVD risk management in new onset diabetes differs from established diabetes. The sodium-glucose cotransporter-2 inhibitors (SGLT2i) empagloflozin and dapagloflozin reduce risk of worsening heart failure, hospitalizations for heart failure, and cardiovascular death. Bempedoic acid combined with other low-density lipoprotein (LDL) lowering agents may be particularly effective in managing lipid abnormalities in people with diabetes. A trial of permafibrate, which reduces triglycerides and increases HDL cholesterol in diabetics, has not been shown to improve cardiovascular outcomes in diabetes and has been discontinued.

CKD and Risk Management
This section is new this year, emphasizing the frequency and importance of renal complications of diabetes. Following albuminuria regardless of estimated glomerular filtration rates (eGFR) with a target of reducing it by 30% in individuals with eGFR <60 mL/min is a new standard. The nonsteroidal mineralocorticoid receptor antagonist finerenone is an option shown to reduce albuminuria, slow CKD progression, and improve cardiovascular outcomes in diabetes. Finerenone should be considered in patients on maximal angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). Combination therapy with glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) may lessen the risk of chronic kidney disease (CKD) as well as CVD. The laboratory formula for estimating glomerular filtration rate (eGFR) has been modified by the National Kidney Foundation and there is no longer a modified calculation for African Americans.

Retinopathy, Neuropathy, and Foot Care
This section was formerly titled “microvascular complications and foot care” and included CKD. Rapid reduction of HbA1c increases the risk of retinopathy; the association of GLP1-RA with diabetic retinopathy (DR) risk is not unique to this class of hypoglycemic agents. The frequency of screening for DR should be risk based and, if found, referral to ophthalmology for treatment and follow-up will be influenced by new recommendations relevant to that specialty.

Older Adults
CGM should be encouraged for older adults with cognitive impairment who can’t perform BGM. The limit of A1C < 8.5% has been eliminated for older adults with history of multiple coexisting chronic diseases or cognitive impairment.

Children and Adolescents
Automated insulin delivery (AID) systems should be offered to children and adolescents with Type 1 diabetes. CGM should be offered to children and adolescents with MODY.

Management of Diabetes in Pregnancy
For pre-conception planning, screen women with risk factors for diabetes; if there has been no pre-conception visit, screen those with risk factors. Before 15 weeks of pregnancy, screen all women for pre-existing diabetes if not done earlier using standard criteria.

Diabetes Care in the Hospital
CGM is recommended to minimize contact between health care personnel and patients with diabetes especially in intensive care because of potential COVID-19 spread.

Diabetes Advocacy
No changes have been made to this section.

References

American Diabetes Association; Standards of Medical Care in Diabetes—2022Abridged for Primary Care Providers. Clin Diabetes1 January 2022; 40 (1): 10-38. https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-2022 (accessed June 16, 2022)
Gabbay R. “Standards of Medical Care in Diabetes – 2022” (video) https://www.youtube.com/watch?v=SgMUWZ8gYG4 (accessed June 16, 2022)
American Diabetes Association Professional Practice Committee; Summary of Revisions: Standards of Medical Care in Diabetes—2022. Diabetes Care1 January 2022; 45 (Supplement_1): S4–S7. https://doi.org/10.2337/dc22-Srev (accessed June 16, 2022)
American Diabetes Association; Introduction: Standards of Medical Care in Diabetes—2022. Diabetes Care1 January 2022; 45 (Supplement_1): S1–S2. https://doi.org/10.2337/dc22-Sint (accessed June 16, 2022)
American Diabetes Association. Standards of Care App https://professional.diabetes.org/content-page/standards-care-app-1 (accessed June 16, 2022)
American Diabetes Association. Important Updates to the Standards of Medical Care in Diabetes—2022 Incorporate New Evidence. Press release May 31, 2022.
https://www.diabetes.org/newsroom/press-releases/2022/important-updates-to-standards-medical-care-diabetes-2022-incorporate-new-evidence (accessed June 16, 2022)